Reproductive
Care Program
of Nova Scotia
NOVA SCOTIA PRENATAL RECORD 1
Patientʼs name:
DEMOGRAPHICS
Maiden name:
Address:
DOB:
Age:
HC#:
Contact telephone #:
Marital status:
Highest level of education completed:
Language:
English French Arabic Other:
Employed:
N
Y Type of work:
Race/ethnicity: Québécois
Acadian
Jewish
African Canadian
Caucasian
First Nations
Middle Eastern
Mediterranean
Other:
Prenatal care provider(s):
(Physician/Midwife/NP):
Babyʼs Physician (in home community):
Partnerʼs Name:
Age:
Race/ethnicity: Québécois Acadian Jewish
Hispanic African Canadian Caucasian
First Nations Middle Eastern Mediterranean
Other:
Language: English
French Arabic
Other:
Employed: No
Yes Type of work:
Hispanic
PREGNANCY DATING
EDD (Best Estimate)
LMP Date: dd/mm/yyyy Sure
N
Y
Regular cycles: N Y
Cycle length:
EDD:
dd/mm/yyyy
OCP stopped: dd/mm/yyyy +ve preg test: dd/mm/yyyy Quickening dd/mm/yyyy
Conception
dd/mm/yyyy
Date: dd/mm/yyyy
Comments:
EDD:
(if known)
weeks
d ays
EDD:
dd/mm/yyyy
Ultrasound
Date: dd/mm/yyyy
weeks
d ays
EDD:
dd/mm/yyyy
Ultrasound
Date: dd/mm/yyyy
weeks
d ays
EDD:
dd/mm/yyyy
18-21 wk U/S Date: dd/mm/yyyy
OBSTETRICAL HISTORY
Date
Gravida
Place
Gest
Para
Mode of Del
Abort
SB
Complications/Comments
Birth Wt
NND
Sex
Health
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
PRESENT PREGNANCY
Pre-Pregnancy Medications
Current Medications
Pre-conceptual folic acid
Depression/anxiety
Bleeding
Received immune globulin
Infections (e.g. UTI,STI)
Nausea /vomiting
Smoking: pre-preg (#/day)
now (#/day)
wishing to quit
Alcohol use
Substance use
Threatened preterm labour
ALLERGIES : Drug
N
N
N
N
N
N
N
N
N
N
N
N
N
N
NKDA
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Comments
Y
Latex
N
PAST ILLNESS
Y
Blood transfusion acceptable
Revised Oct./2013
Tel: 902-470-6798
For Copies contact: RCP of NS, [email protected]
Original-Mother/Hospital Record/Copy-Office Clinical Record
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Operations
Anaes problems
Blood/products
Respiratory
Renal disease
Diabetes
Cardiac
Gynecologic
Thromboembolism
Hypertension
CNS disorder/migraine
Mental health
Substance use
STI
Other
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Comments
Anesthesia consult
N
Y